HIPAA Form

PLEASE ONLY SIGN AND DATE ON THE REQUIRED FIELDS AT THE BOTTOM OF THE PAGE DOWN BELOW! 



AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI)

In order to be compliant with Federal Health Insurance Portability and Accountability Act of 1996 (HIPPA). In an effort to insure privacy of patient Health Information (PHI) necessary for fulfilling our own service to the patient. In an effort to protect the patient, this information will not be used for any other purpose than what has been requested for.

I, hereby authorize to release my medical records to:

Dr. Joshua M. Lippincott D.C.

672 D Gravois Bluffs Blvd.

Fenton, Mo. 63026

636-326-2525

FAX: 636-326-2551

I have read the above information and authorize the above party to disclose the identified information to the person/organization and for the purpose described herein. I understand that, by signing this document, I release and discharge the party from the liability and will hold the said party harmless for any release made pursuant to the authorization. This authorization will expire one year from the date it was signed or otherwise specified.

Name of Person/Organization_________________________________________

Address___________________________________________________________

I specifically authorize the use and disclosure of the following:

 Complete medical record(s) OR Discharge Summary Progress Notes

History and Physical Laboratory Notes

Consultation reports Radiology report

Photographs, videotapes, digital or other images

Other (please specify)

Patient Name:______________________________________ Date of Birth:_______

Social security number:_______________________________ Date of Service:_____

Purpose of request:_____________________________________________________

Thank you for taking the time to fill out this form.

Monday  

8:00 am - 11:00 am

1:30 pm - 6:00 pm

Tuesday  

8:00 am - 11:00 am

1:30 pm - 6:00 pm

Wednesday  

9:00 am - 11:00 am

1:30 pm - 5:00 pm

Thursday  

8:00 am - 11:00 am

1:30 pm - 6:00 pm

Friday  

Closed

Saturday  

Closed

Sunday  

Closed

We look forward to hearing from you

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Please do not submit any Protected Health Information (PHI).

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